Clinical outcomes of Vaginal Natural Orifice Transluminal Endoscopic Surgery (VNOTES) in Gynecology: A Comprehensive Systematic Review and Meta-Analysis

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OBJECTIVE: To evaluate the clinical outcomes of vaginal natural orifice transluminal endoscopic surgery (vNOTES) compared with conventional minimally invasive surgery (MIS), including multiport laparoscopy and laparoendoscopic single-site surgery (LESS), in benign gynecologic procedures. DATA SOURCES: A systematic search of PubMed, Web of Science, and Scopus was conducted from database inception through January 2025. Search terms included "vNOTES" and "laparoscopy." The review was prospectively registered in PROSPERO (CRD42025639454). Only English-language studies were included. METHODS OF STUDY SELECTION: Randomized controlled trials, prospective, and retrospective comparative studies evaluating vNOTES versus MIS in adult women undergoing hysterectomy, adnexal surgery, or myomectomy for benign indications were included. Studies were required to report at least one perioperative outcome. A total of 33 studies involving more than 4,000 patients met inclusion criteria. TABULATION, INTEGRATION, AND RESULTS: Two reviewers independently performed study selection, data extraction, and quality assessment using the Cochrane Risk of Bias 2 tool and Newcastle-Ottawa Scale. Random-effects models were applied. Compared with conventional MIS, vNOTES was associated with significantly shorter operative time (mean difference -25.8 minutes, 95% CI -33.6 to -18.0), lower postoperative pain (mean difference -0.59, 95% CI -1.02 to -0.15), fewer postoperative complications (risk ratio 0.60, 95% CI 0.41-0.87), and shorter hospital stay (mean difference -0.59 days, 95% CI -1.03 to -0.15). No significant differences were observed in intraoperative complications, conversion rates, or estimated blood loss. Prespecified subgroup analyses and meta-regression found no evidence that surgical procedure type modified these associations. CONCLUSION: vNOTES appears to be an effective alternative to conventional MIS for benign gynecologic surgery, offering improved operative efficiency and reduced postoperative morbidity with no statistically significant differences in intraoperative safety. These findings support its integration into minimally invasive gynecologic practice, while further prospective studies are needed to refine indications and patient selection.

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